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Date of Referral
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Person Referring
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Referring Agency
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Phone
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Reason for referral
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Where did you hear about us
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Participant Profile

First Name
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Date Of Birth
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Address
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Last Name
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Gender
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Sburb
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Support Person/ Advocate
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Home Phone
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Mobile
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Marital Status
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Country of Birth
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Work Phone
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Email
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Australian Resident
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Nationality
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Indigenous Status
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Language At Home
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Next of Kin/Carer
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Interpreter Required
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Phone
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Does the participant have decision making assistance
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Informal Decision Maker Contact Details
Areas of decision making?
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Power of Attorney Contact Details
Areas of decision making?
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Public Trustee Contact Details
Areas of decision making?
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Enduring Power of Attorney Contact Details
Areas of decision making?
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Adult or Appointed Guardian - Copy of order available
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Contact Details
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Conditions

Does the participant have any physical health condition?
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Does the participant have a mental health condition?
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GP
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Case Manager
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Treating Specialist
Your Full Name
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Phone
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Does participant have any cognitive disability?
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Does the participant have access to funding?
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Name Source?
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Does the participant currently have an Individual Funding package?
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Does the participant have any behaviours of concern?
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If yes, describe
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Does the participant have an approval for Restrictive Practices?
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If yes, expiry date
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Does the participant have a Positive Behavioural Support Plan in place?
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If Yes
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Alerts/Risks/Precautions***
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Current Community Supports:
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Type of Accommodation:
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Additional Information:
How does the participant Communicate :
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What support/assistance or services is the participant looking for ?
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I give my consent for this Intake form to be passed on to the staff at Uprety Home Care.

Name
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Signature
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Where did you hear about us?
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Do you wish to receive mail outs from Uprety Home Care:
If yes, provide address
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OFFICE USE ONLY

Participant File created: By (Uprety Home Care) :
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